MEDICARE: MARQUIS EVERETT BOURNE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0019X	Physical Rehabilitation Occupational Therapist	OP007808	PA

General Provider Information

NPI Number	:	1386404192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARQUIS EVERETT BOURNE

Provider Business Mailing Address
First Line	:	1526 LOMBARD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1625
Country	:	US
Telephone Number	:	215-546-5960
Fax Number	:

Provider Business Practice Location Address
First Line	:	5842 FLORENCE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-4530
Country	:	US
Telephone Number	:	215-546-5960
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	03/20/2024

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Directions to “ MARQUIS EVERETT BOURNE ” Practice Location

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